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TOXIDROMES. Searching for Clues. HISTORY. When to suspect Approach to known exposure Approach to unknown exposure. PHYSICAL EXAMINATION. VS Eye exam Skin Neuro. APPROACH TO TREATMENT. Early and effective decontamination Supportive therapy Antidotes Enhanced elimination.

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history
HISTORY
  • When to suspect
  • Approach to known exposure
  • Approach to unknown exposure
physical examination
PHYSICAL EXAMINATION
  • VS
  • Eye exam
  • Skin
  • Neuro
approach to treatment
APPROACH TO TREATMENT
  • Early and effective decontamination
  • Supportive therapy
  • Antidotes
  • Enhanced elimination
laboratory exam
LABORATORY EXAM
  • Anion gap, acid-base status, osmolar gap
  • BUN/creat, UA
  • ECG
  • Abd film
  • CXR
  • Toxicology screen
toxic syndromes and drug overdosages
TOXIC SYNDROMES AND DRUG OVERDOSAGES
  • Physiologic stimulants
  • Physiologic depressants
  • Other drug overdosages
physiologic stimulants
PHYSIOLOGIC STIMULANTS
  • Anticholinergics
  • Sympathomimetics (ex. cocaine)
  • Hallucinogens
  • Drug withdrawal
  • Miscellaneous (thyroid hormones)
anticholinergics
ANTIHISTAMINES

ANTIPSYCHOTICS

BELLADONNA ALKALOIDS

CYCLIC ANTIDEPRESSANT

CYCLOBENZAPRINE

PARKINSON’S DZ DRUGS

GI/GU ANTISPASMODICS

MYDRIATRICS

PLANTS/ MUSHROOMS

ANTICHOLINERGICS
anticholinergics atropine
ANTICHOLINERGICS: ATROPINE
  • CLINICAL PRESENTATION
    • “Hot as a hare, dry as a bone, mad as a hatter”
    • Dryness of mouth
    • flushed, hot, dry skin
    • dilated and nonreactive pupils
    • tachycardia
    • hallucinations, restlessness
anticholinergic atropine
ANTICHOLINERGIC: ATROPINE
  • TREATMENT
    • Gut decontamination
    • Physostigmine
    • Supportive care
cocaine
COCAINE
  • CLINICAL PRESENTATION
    • tachycardia, HTN arrhythmia
    • can get hypotension and reflex bradycardia
    • CNS stimulation
cocaine1
COCAINE
  • TREATMENT
    • CNS sedation
    • Labetolol
    • Treat hyperthermia
    • ?Parlodel or desipramine
hallucinogens
Hallucinogens
  • Stimulation of serotoninergic system
  • Illusions, visual hallucinations, sweating, tachycardia, pupillary dilatation
  • Usu done in 12 hours
  • No true withdrawal state
hallucinogens1
Hallucinogens
  • Treatment
    • Generally do not require medical treatment
    • Can use benzodiazepine for agitation
    • Reduce stimuli
    • Discontinuation can result in dysphoria from reduced serotonin activity. SSRI can be used for 3-6 months
physiologic depressants
PHYSIOLOGIC DEPRESSANTS
  • Cholinergics
  • Narcotics
  • Symphatholytics (cyclic antidepressants)
  • Sedative-hypnotics
  • Miscellaneous (carbon monoxide)
cholinergics
BETHANACOL

CARBAMATE INSECTICIDES

MYASTHENIA GRAVIS DRUGS

EDROPHONIUM

PHYSOSTIGMINE

PILOCARPINE

NICOTINE

CHOLINERGICS
cholinergics clinical presentation
CHOLINERGICS: CLINICAL PRESENTATION
  • DEFECATION
  • URINATION
  • MIOSIS
  • BRONCHO- CONSTRICTION
  • BRADYCARDIA
  • EMESIS
  • LACRIMATION
  • SALIVATION
cholinergics1
CHOLINERGICS
  • TREATMENT
    • Gastric decontamination
    • Respiratory support
    • Atropine
    • Pralidoxime
    • Cardiac monitoring
    • Tx seizures with benzodiazipine
opiates
CLINICAL PRESENTATION

Pinpoint pupils

Respiratory depression

Bradycardia

Hypotension

Hypothermia

Pulmonary edema

Seizures

OPIATES
opiates1
OPIATES
  • TREATMENT
    • Acute
      • Naloxone
    • Chronic
      • Methadone
      • Catapres
      • Naltrexone
opiates2
OPIATES
  • POSSIBLE COMPLICATIONS
    • Aspiration
    • Pulmonary edema
    • Withdrawal symptoms
    • Need for repeated doses
benzodiazipines
BENZODIAZIPINES
  • CLINICAL PRESENTATION
  • Respiratory depression
  • Drowsiness
  • Coma
benzodiazipines1
BENZODIAZIPINES
  • TREATMENT
    • Generally requires no pharmacologic intervention
    • Flumazenil
cyclic antidepressants
CYCLIC ANTIDEPRESSANTS
  • CLINICAL PRESENTATION
    • Most are combination anticholinergic and sympatholytic
    • Coma
    • Seizures
    • Hypotension
    • Cardiac dysrhythmias
cyclic antidepressants1
CYCLIC ANTIDEPRESSANTS
  • TREATMENT
    • Gastric decontamination
    • Treat cardiac dysrhythmias
    • Treat seizures
carbon monoxide poisoning
Carbon Monoxide Poisoning
  • Most common cause of death by poisoning
  • Symptoms vary:
    • Mild: HA, mild dyspnea
    • Mod: HA, dizziness, N/V,dyspnea, irritability
    • Severe: Coma, seizures, CV collapse
carbon monoxide poisoning1
Carbon Monoxide Poisoning
  • Most common cause of death by poisoning
  • Symptoms vary:
    • Mild: HA, mild dyspnea
    • Mod: HA, dizziness, N/V, dyspnea, irritability
    • Severe: Coma, seizures, CV collapse
other drugs
DISSOCIATIVE DRUGS

ACETOMINOPHEN

SALICYLATES

DIGOXIN

SEROTONIN SYNDROME

LITHIUM

“CLUB DRUGS”

OTHER DRUGS
dissociative drugs
DISSOCIATIVE DRUGS
  • Ketamine, Phenycyclidine (PCP), Phenylcyclohexylpyrolidine (PHP)
  • Acts on all six neurotransmitter systems
    • Anticholinergic: dry skin, miosis
    • Dopamine/norepinephrine:agitation, delusions
    • Opioid:pain perception alterations
    • Serotonin: perceptual changes
    • GABA receptor inhibition: excitation
dissociative drugs1
DISSOCIATIVE DRUGS
  • Treatment
    • Haloperidol
      • Presynaptic dopamine antagonist
      • Shifts the dopamine-acetylcholine activity ratio in the limbic system
      • Therefore can counteract the dopamine stimulation and cholinergic antagonism of the drug
acetaminophen
ACETAMINOPHEN
  • CLINICAL PRESENTATION
    • No specific symptoms or signs
acetaminophen1
ACETAMINOPHEN
  • TREATMENT
    • Gastric decontamination
    • N-acetylcysteine
salicylates
SALICYLATES
  • CLINICAL PRESENTATION
    • Mixed acid-base disturbances
    • GI: N/V, abdominal pain
    • CNS: tinnitus, lethargy seizures, cerebral edema, irritability
    • Resp: pulmonary edema
    • Coagulation abnormalities
digoxin
DIGOXIN
  • CLINICAL PRESENTATION
    • Nausea/vomiting
    • Mental status changes
    • Cardiovascular symptoms
digoxin1
DIGOXIN
  • TREATMENT
    • Gastric decontamination
    • Fab fragments
serotonin syndrome
SEROTONIN SYNDROME
  • CLINICAL PRESENTATION
    • Neurobehavioral: mental status changes, agitation, confusion, seizures
    • Autonomic: hyperthermia, diaphoresis, diarrhea, tachycardia, HTN, salivation
    • Neuromuscular: myoclonus, hyperreflexia, tremor, muscle rigidity
serotonin syndrome1
SEROTONIN SYNDROME
  • TREATMENT
    • Respiratory support
    • Temperature control
    • Sedatives
    • Muscle relaxants
lithium
Symptoms

GI: vomiting, diarrhea

Neuro: tremors, confusion, dysarthria, vertigo, choreoathetosis, ataxia, hyperreflexia, seizures, opisthotonis, and coma

Labs: decreased anion gap

Treatment

Levels >2.5 meq/L

Gastric lavage

Urinary alkalinization

Not very effective

Aminophylline

Hemodialysis

>3.5 mEq/L (acute)

>2.5 w/ chronic ingestion or renal insufficiency

LITHIUM
club drugs
Rave parties increasing in popularity

Drugs meant to intensify sensory experience of lights/music, facilitate prolonged dancing

“CLUB DRUGS”
mdma ectasy
Structurally resembles amphetamine (stimulant) and mescaline (hallucinogen)

SX: trismus, bruxism, tachycardia, mydriasis, diaphoresis, hyperthermia, hyponatremia, hepatic failure, CV toxicity (tachycardia, HTN)

Treatment

Mainly supportive

Benzodiazepines

Calm environment

Avoid beta-blockers

Can result in unopposed alpha effect

If essential consider labetolol

MDMA “Ectasy”
ghb date rape drug georgia homeboy liquid ectasy or grievous bodily harm
Developed as anesthetic agent. GABA analog

Symptoms

Bradycardia

Hypothermia

hypoventilation

Somnolence

Vomiting

Myoclonic jerking

Treatment

Conservative mgmt

Intubation

Careful exam for sexual assault

GHB: Date rape drug“Georgia homeboy, liquid ectasy, or grievous bodily harm”
ketamine k special k
Developed as an anesthetic, structurally resemble PCP

Symptoms

Nystagmus

Tachycardia

HTN

vomiting

Treatment

Benzodiazepines

Supportive care

IV

Can consider urine alkalinization

Ketamine: “K”, “special K”
clinical scenario 1
CLINICAL SCENARIO 1
  • A 48 year old unconscious woman is brought to the hospital. She is convulsing and has an odor of garlic on her breath. She is incontinent for urine and stool. On exam her VS: T99, HR50, RR24, BP146/88. Skin is diaphoretic. She is drooling. Pupils are constricted. Lungs diffuse wheezing.
clinical scenario 11
CLINICAL SCENARIO 1
  • Recognize: Cholinergic poisoning
  • Treatment:
    • Gastric decontamination
    • Respiratory support
    • Cardiac monitoring
    • Atropine followed by pralidoxime
    • Treat seizures with benzodiazepine
clinical scenario 2
CLINICAL SCENARIO 2
  • 17 year old male presents to the hospital with somnolence, slurred speech, and combative behavior. His younger sister said he showed her a handful of small seeds that he was going to take. On exam his VS: T102, HR120, BP100/60, RR22. Skin is hot and dry. Mucous membranes are dry. Pupils are dilated and not reactive.
clinical scenario 21
CLINICAL SCENARIO 2
  • Recognize: Anticholinergic poisoning
  • Treatment
    • Supportive care
    • Physostigmine
      • Coma
      • Arrythmias
      • Severe HTN
      • Seizures
clinical scenario 3
CLINICAL SCENARIO 3
  • 26 y/o male presents unresponsive. His friend accompanies him and states he took a handful of pills because he was in pain. On exam his VS: T96, HR40, RR6, BP50/30. Pupils are 3mm.
clinical scenario 31
CLINICAL SCENARIO 3
  • Recognize: Opioid poisoning
  • Treatment
    • Naloxone
summary
Summary
  • Don’t panic!!
  • Recognize your clues
  • Look for the toxidrome syndrome